RV Insurance Binder Request Form
Date: __________
Name (Renter): ____________________
Your insured, _____________________ is currently planning on renting a motorhome from John S Pitcher (Arizona RV Rental, LLC) (“Owner”). Your insured has chosen to have his/her personal vehicle insurance as primary insurance for the period of this rental. In order to fulfill the request of your insured, a Binder is required. The binder or endorsement should cover the vehicle and name the Owner as an additional insured. In order to satisfy our requirements, the insurance provided by you must include primary comprehensive and collision coverage and primary liability coverage. This promise of primary insurance coverage may amend the terms of your policy.
Your policy must cover up to the actual cash value of the rented motorhome. The estimated value of the motorhome your insured will be renting is $50,000. The limits of liability coverage must be at least the minimum limits as required by any applicable compulsory or financial responsibility law. The loss payee should be listed as John S Pitcher (Arizona RV Rental, LLC) (Owner). No collision or comprehensive deductibles shall exceed $500.00.
Insurance Binder effective from _____________ 12:01 AM. through ____________ 11:59 PM.
1. Manufacturer, Make, and Model: Eclipse Stellar 28 IBLG
2. Towable or Drivable Unit: 33ft Towable Unit
3. Length of Unit: 33ft
4. Vehicle Identification Number (VIN): 5LZBT2826FR042696
5. License Plate State And Number State: AZ, Plate Number: 31173-B
6. Gross Vehicle Weight (GVW): 7200 Lbs
Please email a Binder of Endorsement ASAP to:
Rental Owner Name: John Pitcher (Arizona RV Rental, LLC)
Address: 2977 E Teakwood Place
City: Chandler State: AZ Zip: 85249
Thank you in advance for your prompt attention to this matter. Please sign and email or fax back this request form with binder or endorsement.
_________________________________________________
Agent / Representative
_________________________________________________
Agency / Insurance Company
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